Salivary gland diseases Flashcards
How do you examine salivary glands? (2)
- Visually - front, side and behind pt
- Palpate
Which nervous pathway increases salivary flow?
Which decreases salivary flow?
Incr = Parasympathetic - cholinergic
Decr = Sympathetic - adrenergic
What CN innervates submandibular and sublingual gland? Incr salivary flow?
CN7 - facial nerve, chorda tympani
What CN innervates parotid gland? Incr salivary flow?
CN9, glossopharyngeal - lesser petrosal nerve
What CN innervates minor salivary glands? Incr salivary flow?
Both CN7 and CN9 - facial nerve and glossopharyngeal
How does the sympathetic, adrenergic pathway work? To decr salivary flow? (5)
- Sympathetic outflow
- Cervical ganglia
- Plexus along artery walls
- Branches to CNs
- Innervates salivary glands
What does saliva contain?
99.4% water
0.6% minerals and proteins
- Inorganic = sodium, potassium, chloride, bicarbonate, hydrogen, iodine, fluoride, calcium phosphate
- Organic = urea, uric acid, AAs, glucose, lactate, fatty acids
- Macromolecules = serum proteins, glycoproteins, peroxidases, amylase, lysozymes, IgA, IgG, IgM
What is the flow rate of saliva stimulated and non stimulated?
Stimulated = 4 - 5 ml/min
Non stimulated = 0.3 - 0.4 ml/min
How can you investigate salivary gland disease? (7)
- Sialomertry
- Oral rinse
- Plain film radiography
- Ultrasound
- Bloods
- MRI
- Biopsy
How is Sialometry used?
- Measure of saliva produced ml/min over 5-10mins
- Crude technique, not used in practice
How is plain film radiography used?
- Identifies radio opaque calculus
- Needs 2 radiographs at 90 degrees to each other
How is Ultrasound used?
- High freq sound waves can identify solid lesions incl. tumours / calculus / cysts
- Not good for assessing salivary gland function
How is Sialography used?
- Retrograde sialography examines ductal system using radio iodide
- Shows structures, filling defects
- Not good for investigating salivary tumours
How are bloods used?
- Venous blood sample for xerostomia pt
- Sjogren’s screen involves - FBC, liver function tests, urea, electrolytes, HbA1C (glucose test), serum immunoglobulins, hep C and HIV serology
What is Sjogren’s syndrome?
- Autoimmune disease affecting exocrine glands
- Effects moisture production
How is MRI used?
- Magnetic Resonance Imaging
- Demonstrates soft tissue detail
- Ideal to see tumour extent and relation to normal anatomy
How are biopsies used?
Excisional for minor SGs - done IO
Incisional for major SGs - done IO / EO
What are symptoms of salivary gland diseases?
- Swellings - localised / generalised / uni / bi-lateral / persistent / transient
- Pain
- Discharge from SG duct
- Xerostomia / Sialorrhoea
What are the 11 salivary gland diseases need to know?
- Obstructive
- Xerostomia
- Sialorrhoea
- Sarcoidoisis / HIV related SG disease
- Cancers
- Benign neoplasias
- Benign cysts
- Acute / chronic sialadenitis
- Frey’s syndrome
- Developmental abnormalities
- Primary / secondary Sjogren’s syndrome
What are main causes of obstructive SG disease?
- Calculi
- Strictures (narrowing of duct)
- Infections
Define sialadenitis?
How is it categorised?
Inflammation of salivary gland
Infective
Obstructive
What else may cause obstructions of salivary glands?
- Local swellings e.g. from cancers / lymph nodes
Describe salivary gland calculi
- AKA Sialoliths
- Most common cause of obstructive sialadenitis
- Usually major salivary glands
- Hard
- Single / multiple
- 80% involve submandibular gland
- Can be asymptomatic
What causes strictures?
Trauma to the duct followed by fibrosis
Nearly all acquired
How common are strictures?
Less common than calculi / mucus plugs
How can localised strictures be treated?
Balloon dilation
But future re-stenosis may occur
What causes an acute obstruction and how is it described? How does it resolve?
Calculus / mucus plug
Recurrent, before eating, painful swelling of major SG
AKA mealtime syndrome
Resolves within 30 mins
How to manage calculi?
- If asymptomatic - leave
- If symptomatic and small can remove by incising to release stone
- If symptomatic and large can retrieve endoscopically or remove whole gland
What are some of the associated risks when removing submandibular gland?
- Damage to marginal mandibular nerve
- Damage to lingual nerve
- Damage to hypoglossal nerve
What are some of the associated risks removing parotid gland?
- Damage to facial nerve, lading to unilateral facial weakness
- Frey’s syndrome
What is the difference between hypo salivation and xerostomia?
Xerostomia = perception of dry mouth - subjective
Hyposalivation = reduced saliva production - objective
What can cause xerostomia? (9)
- Medx
- Diabetes
- Anxiety
- Mouth breathing
- Dehydration
- Irradiation to salivary glands
- Acute infections
- Recreational drug use
- Sjogren’s syndrome
Which mechanisms cause drugs to suppress saliva production?
Central effects to brain
Anti-muscarinic effects
Sympathomimtrics (stimulate sympathetic nerves)
Name some prescribed drug groups which cause xerostomia
- Tricyclic depressants
- MAOIs
- Antihistamines
- Diuretics
- Antipsychotics
- Antiparkinsonian
GDP level how can you manage xerostomia (11)
Smoking cessation
Alcohol cessation
Advise increase H20 intake
Avoid caffeinated drinks
Sugar free gum
Dietary advice to avoid cariogenic foods
F- intake through toothpaste / mouthwash / FVA
Increase freq of dental check ups
Discourage mouth breathers
Treat oral candidoses
Prescribe saliva substitute
Why aren’t saliva substitutes / oral lubricants suitable for all pts? (3 examples)
- Glandosane = acidic can cause erosion, so only suited to edentulous pts
- BioXtra = made of cow’s milk, pt dietary preferences (unsuitable for vegans or lactose intolerant)
- Saliva Orthana = made of porcine proteins, unsuitable for Muslim and Jewish pt
What is Sialorrhoea and what is it also known as?
- Ptyalism
- Hypersalivation
Excessive production of saliva
What can cause Sialorrhoea?
Parkinson’s
Cerebral Palsy
Acute viral infection
Rabies
Pregnancy
Teething
New dentures / orthodontist appliance
Pancreatitis
Mercury / Copper / Arsenic poisoning
Side effects of drugs
How can Sialorrhoea be managed? (3)
Anti-muscarinics
Botox
Surigcally excising the gland
How does Botox manage Sialorrhoea?
Injected into the salivary gland
Reduce ACh release
Inhibiting salivation
What are the side effects of anti-muscarinics?
Can be worse than hypersalivation itself
- Urinary retention
- Constipation
- Overheating due to inhibited sweating
What is sarcoidosis / HIV related salivary gland disease?
Chronic, multi-system, non-caseating granulomatous inflammatory disease of unknown cause
What is sarcoidosis characterised by?
Enlarged lymph nodes across many parts of the body
What can sarcoidosis / HIV related salivary gland disease cause?
SG swelling
Bilateral of parotids
Xerostomia
What does HIV SG disease involve?
- Uni/bilateral parotid gland swelling
- Can cause cystic changes in SGs
What is graft versus host disease a consequence of? How does it happen?
Transplants e.g. bone marrow transplant
Lymphocytes from the donor recognise recipient cells are foreign - so graft attacks the host
What can be commonly seen in GvHD?
Xerostomia
Oral lichenoid lesions
Generalised mucosal inflammation
Candidoses
Oral hairy leukoplakia
What are the 2 categories of SG cancers? Give examples
Benign neoplasms - pleomorphic adenomas, Warthin’s tumour
Malignant neoplasms - lymphoid, mucoepidermoid (common in parotid), adenoid cystic carcinomas (common in submandibular gland)
Radiotherapy may be used for primary / secondary malignancies - which cells are most susceptible?
Serous cells > mucus cells
What is glandular tissue replaced by following irradiation?
Reparative fibrosis
What happens to saliva following radiotherapy?
Saliva production decreases and becomes thick with altered biochemistry and properties
What are most benign neoplasias and which SG are they mostly found in?
Pleomorphic adenoma - 80%
Parotid gland
Describe pleomorphic adenoma
Poorly encapsulated
Slowly enlarge over many years
Rarely become malignant
How common are Warthin’s tumours? Describe and how are they managed?
Less common than PAs
Well encapsulated compared to PAs so surgical excision easier
What is a mucocele an example of?
Benign cyst of minor SG
(Dilatation and accumulation of mucus)
What is the main pt complaint with benign cysts?
Annoying and unaesthetic
Present as recurrent / persistent swellings in lower lip / buccal mucosa
What does a mucocele in the upper lip suggest?
SG neoplasia - advise excision biopsy
What is a ranula?
Sialocyst in FoM from sublingual SG
Type of mucocele
Unilateral
Raises tongue
(Frog like appearance)
How is a ranula managed?
Marsupialisation - surgically cutting slit into cyst and suturing edges
Excision - rare
What is Sialadentiis and what’s its origin?
Inflammation of SGs - acute or chronic
Viral origin - Mumps, CMV, HIV
Bacterial origin - Streptococcal or staphylococcus infection
Which SG is acute sialadentis mostly seen?
Parotid
Which SG is chronic sialadentis mostly seen?
Submandibular
Signs of acute bacterial sialadentis
- Parotid
- Systemically unwell
- Signs of acute inflammation
- Pus drains into mouth
- Foul taste
- Erythema, heat and swelling EO (anterior to ears)
How is acute bacterial sialadentis managed?
- Acute symptoms need to be managed
- ABX
- Hydration and antipyretics
- OHI to reduce reinfection risk
Why is it more likely to get recurrent / chronic sialadentis after 1st exposure?
Fibrosis from initial inflammation
Signs of chronic bacterial sialadentis
- Submandibular gland
- Evolves of period of months
- Inflammation gets progressively more fibroses
- Strictures / calculi
- Sjogren’s syndrome
- Intermittent pain, general aching / tenderness
- Occasional pus secreted
How is chronic sialadentis managed?
Surgical removal of gland
What is Frey’s syndrome?
Neurological disorder
Damage to / near parotid glands
Damage to autonomic nerves supplying skin sweat glands and SGs
Signs of Frey’s syndrome
- Facial sweating
- Facial flushing
Management for Frey’s syndrome
Botox injections
What kind of SG developmental abnormalities can occur?
Atresia = total absence of SGs
Hypoplasia = shrunken appearance of SGs
Are there are symptoms from SGs with developmental abnormalities?
Asymptomatic usually
Other glands make up for reduced production from shrunken / missing SG
What usually goes with primary / secondary Sjogren’s syndrome?
Systemic autioimmune condition
E.g. Rheumatoid arthritis RA
Systemic lupus erythematous SLE
What does Sjogren’s syndrome affect?
Internal exocrine glands in pancreas, bowel, kidneys
Who is affected by SS?
Females
2%
15% of RA pts have secondary SS
30% of SLE pts have secondary SS
What can trigger SS?
Genetic predisposition
Herpes virus
Hep C
Systemic signs of Sjogren’s syndrome
- General fatigue - severe and debilitating
- Inflammatory vascular disease
- Raynaud’s syndrome - no blow flow to areas of body (causes it to appear white then blue)
- Thyroiditis
- Anaemia
What are some subjective symptoms of xerostomia in pts with SS?
- Nutritional deficiences
- Difficulty swallowing / chewing
- Sensitivity to spice
- Salty bitter metallic taste
- Burning mucosa
- Lack of taste
- SG swellings / pain
- Cough
- Altered saliva quality
- Difficulty speaking, vocal disturbances
- Lack of denture retention
What are some objective signs of SS related to oral cavity?
- Oral mucosa = dry, wrinkled, ulcerated, frothy saliva, lack of pooling of saliva in FoM
- Tongue = dry, red, loss of papilla
- Teeth = more caries, failed / fractured restorations
- SGs = firm on palpation
How to differentiate between primary and secondary SS?
- Primary = dry mouth + eyes
- Secondary = dry mouth + eyes + connective tissue disease
What is Sicca syndrome?
- Pts with dry mouth + eyes
- But do not have SS
- No other explanation for symptoms
How to manage Sjogren’s syndrome
Palliative measures
- Increase lubrication
- Maintain OH
- Immunomodulating agents
- Pilocarpine - primary SS but side effects
What is Sialosis?
- Painless enlargement of major SGs
- Bilateral and symmetrical
- Soft to palpate
- No xerostomia
- No fever
- No trismus
- Uncommon
What is sialosis associated with?
Alcoholism
Pregnancy
Diabetes
Anorexia
Bulimia
